Friday, 23 January 2009

Wards

I'm not happy with wards.

Well, to be blunt, I'm not happy with the standards of care on acute medical and surgical wards.

I'm not in the habit of bashing colleagues, so I won't. There may well be understandable reasons for why care has been poor. I honestly don't imagine that staff got up in the morning and thought, "I know, I'll go to work today and do a rubbish job!" I trust that the instituationalisation of the ward staff and the management structure's edicts have significantly contributed to (if not generated) this state of affairs.

But, understandable or not, nurses fault or not, the consequence is still that care has been poor. Unacceptably so.

I have to travel to the acute district general hospital to see their patients, doing the liaison psychiatry work for them. Visiting patients has become a more frustrating process, of late. Parking is a nightmare, so how can I even get to see their patients? But when I do finally get to the ward, it's mostly empty. Usually I just wander on, look for a qualified nurse, can't find one, find if the patient's on the ward by looking on the whiteboard on the wall (no confidentiality here, you see), go to the notes trolley by the door then rummage around and pull out notes (odd that these notes are openly kept in a public area, without supervision, and I've never never been challenged on picking up a set of notes) and get the measure of what's going on. I then find anyone (really, anyone) who can tell me something about the patient's course of late, whilst on their in-patient unit. Once it was a lady pouring tea, who could say my patient had got worse and left her drinks now (had done since last Tuesday), left her meals too come to think of it, and just lay in bed (because the nurse in that bay "was off" and no qualified or unqualified nurse on the ward on that shift knew anything about the patient).

So I drive to their hospital, park up eventually, get to the ward, find notes, find some information, then finally get to see their patient for them.

Recently I saw on lady on the ward who I've been looking after in the community. She has Alzheimer's disease (F00.112) and was getting frailer and more confused, but deficits weren't typical. I thought she'd an acute confusional state so arranged investigations which found her to have pancytopaenia, she was admitted and clever haematologists did genuinely clever things, improving her significantly. They were unsure if she could return home and if her drug regimen was adding to lethargy so asked for advice. When I saw her on the ward, she was lying in urine. She'd been incontinent (because she is). I went to find someone to sort this out, who attended and sighed, scolded her for "not pushing the buzzer" and blamed the patient. The patient has severe dementia. She has no idea what the buzzer is or what it achieves and certainly wouldn't be inclined to push buttons and coloured lights on dashboards on an acute medical ward. The healthcare assistant had no idea that her patient was demented, or what that meant. Folk with dementia really get woeful care on that acute ward, persistently, staff simply have no notion of how dementia affects patients.

Another ward, another patient. Again, someone I know. He's had major surgey and is on a high dependency unit with 1 : 1 nursing. Fabulous. I have a sense of deja vu here as, once again, I see the same thing as has happened before.

My patient's face lights up as he sees me (no idea why, it's the CPNs who've done the most for him, but I guess he's genuinely happy to see a familiar face). I enquire how he's been today, he says he's bored because he can't do anything. He gestures to one arm strapped up (from his orthopaedic surgery) with tubes coming out of it. He nods to the newspaper in front of him which his son had brought in, but he can't ready today. Why not? The nurses haven't got his glasses, he's bedbound and can't get them, the nurse is too busy and chided him for wanting a drink earlier so he daren't ask her for his spectacles. His bag's right behind his bed, I reach down, pull them out, hand them to him. He beams. I'm seeing him at lunchtime (the only time through the day I can, since it's only between morning and afternoon out-patient clinics that I can find parking) and his lunch is on a tray in front of him. He's lying in a bed, with the head end tipped up a little. The tray is across his chest. On it is a shepherd's pie and carton of juice and a cake. The juice and cake are sealed. He has just one usable hand. I look at the food, look at him, look at the food, look at him and he bursts out and laughs, knowing exactly what I'm thinking. "One hand, yes doc, clever isn't it?" He gestures at the foil lid and the cellaphane wrapped muffin knowing he's got no chance.

My third patient is sitting in bloody diarrhoea.

My fourth patient is being taken home by family, against medical advice, despite being an incapacitated vulnerable adult and having nursing and medical and OT and social workers formal written statements and assessments detailing her needs and how these could only be meet within a 24 hour nursing care home. But it's easier to let her go and have no care than argue with the vocal and critical family. So it goes.

My fifth patient isn't there any more. She was admitted with confusion on top of her bipolar mood disorder, was found to have had a heart attack, and had died 2 days later (may she always rest in peace). I wonder what her last few days were like. She was often bewildered and afraid in unfamiliar settings. If my kith or kin had to die in hospital, I truly hope their last days are in a better place than this, with folk who really are in a position to give care.

17 comments:

Your experiences sound terrible. However, I was on a high dependency ward for a night last May following hip replacement surgery and cannot speak highly enough of the care I received. The nurses were attentive to my every movement (which in spite of morphine for the pain were frequent) and were kind and friendly beyond belief. I didn't want to leave the unit to go back to the normal ward (not because care there was substandard, but because I felt so bloody awful!).

It's a familiar tale but - it has to be said - if the visiting Consultant Psychiatrist doesn't evoke a better reaction than this from the staff - what are the chances of anyone?

These are the times when your integrity gets challenged the most - when your own system and service (albeit tangential to your core duties) provides to such a low standard - and you feel thwarted by politics or "professional courtesy" to avoid erupting.

There are usually "quality improvement" practices in hospitals nowadays but run by the nursing team managers. How about your CPNs or NPs drop by and 'have a chat'?

It's interesting for me that you posted this, because I work two evenings on an elderly medical ward. All the same scenarios really.Yet the simplest of things could help these patients to eat, drink, read magazines/books, be comfortable and clean in bed.None of it is rocket science, just a bit of care and common sense. It may be down to staffing, although I'm not sure that is the whole truth behind the shocking treatment of our elderly. More often than not there's not enough health care assistants to help the patients.For some reason the staff nurses and senior staff nurses don't seem to get involved with general care issues other than giving out meds.I get annoyed with them when I see them sitting at the nurses station not doing any obvious work.I ask questions about which member of staff is dealing with which patient, because (and I do not want to seem big headed ) I care and it's me who notices an awful lot going on with the patients that the nurses do not see. Or the patients ask me to help them and I am simply not allowed to. Things like feeding them, putting them to bed, cleaning them up etc.It's probably unusual for staff in my position to be asking so many questions. Part of the problem is with the way things are managed on that and many other wards (not just elderly). There's not enough team working going on.It's fine to have a specific nurse allocated to a patient but if that nurse is on a break or dealing with another patient who is going to deal with the patient sitting in soiled clothes? It is truelly heartbreaking to see the way our elderly are treated, yet for some reason the NHS cannot seem to deal with elderly care in such a way that is humane and caring.It isn't right, it isn't fair and I want to know what the hell is going to be done about it other than churning out various directives on pieces of paper that amount to absolutely nothing.

Jayann, I think it is largely (OK not totally) staff shortages. For sure, it is bad, no appalling, nursing care. But there are not enough hand on nurses to go round. I keep saying this, over and over again. I think I have said it so many times that no one takes any notice any more. Until their elderly relative is in hospital.

One of the residents who works with me, whose father is also a doctor, said that his father made a family rule that no one in the family dies in the hospital. They don't call ambulances, don't do this advanced dementia care, nothing. I have to sort of admire them.

And I too have seen the horrible conditions - general internal medicine is the worst. It seems to be a catchall for so much of what you describe.

We have implemented geriatric assessment nurses that float everywhere - from admissions to emergency to the wards who try to remedy these problems (the missing glasses, mobility, full geriatric assessments). They are very good, but there are 2 of them for the whole hospital.

When I did my week in adult nursing I was often horrified by the state people were left in over periods of time. What horrified me most though was the fact that we didn't have time to help them all. The ward was so short staffed that we simply couldn't keep up with what needed doing. I felt shit, basically, and would never want to do that full time.

Conversely however, I was appalled when my mum went in for a hip replacement and was left lying covered in her own vomit all night after a bad reaction to the anaesthetic. This time there was no excuse; it was a quiet ward and the next night she caught one of the nursing assistants asleep under a desk. She had had the same op at another hospital previously though and had spoken well of the nurses there.

I did a single shift on an acute medical ward last year, that was enough for me. I have forever embedded in my mind the image of the HCA trying to force feed a patient with severe dementia, who had just woken up and was quite clearly confused. It was horrific. I hoped that I had just caught them on a 'bad day' though I suspect not.

I think better training should be provided with regards mental health issues on general wards especially with regards to dementia and it's effects on people.

I see this all the time, talk about it all the time and wonder how it could ever get better. I was a nurse up until 2000, when I became a paramedic. Even back then I could see the demise of "basic nursing care". I keep thinking that everything is cyclical and constantly hope that the concept of looking after the patients basic fundemental needs rather than only their current physical illness comes back sometime soon.

Cannot help thinking each time have read this it would have taken seconds to rip the plastic cover of the cake and open the juice carton.

Worked for short time cleaning in NHS hospital which also involved meals and so on (breakfast, dinner) if we saw something like that it was nothing to just add that extra "do you want me too....."as you delivered the meal or collected the plates from each bed.

Having said that saw much of what you said, whilst delivering tea one day a patient asked for sugar something just clicked at the unusual amount so questioned it, the sign should have been there she was diabetic...it was not..thankfully did not give it to her,then the staff nurse came finally getting out the sheet should have had prior, these were old ladies with dementia, who had no idea of their needs, not even that they should not have sugar, often asked the visitors if they wanted a cup of tea, they seemed overwhelmed sometimes at someone going out of their way, as they asked for something would always see if i could get it or pass it on.

One old lady went on a ward (traveled round 5 in a shift) was sat in a room on her own, with no top clothes on, waiting for a wash or something, went for my break and half an hour later she was still sat in the same position.

Was just a cleaner, but felt it was very wrong, some wards were excellent some were not.

Disliked the ward with the old ladies on suffering varying forms of dementia as much of what you wrote was visible, it was quite thought provoking to think that perhaps you may yourself end up like that and in that situation some day. Hopefully, there would be caring people around who would think nothing of giving that few extra moments just to do something simple for you.

But if we treat out people like this now, what hope is their for the next generation of elderly?

I find it some kind of relief (but not much) that a consultant is saying how awful it is on wards.

Usually it is up to the inmates (those who are able enough or have anyone willing to listen to them) to have some kind of say. Not so much on the wards but when they get off them.

I feel really pxssed off at the lack of care provided in these places.

And let's make no bones about it...quite a bit of what is supposed to go on in wards does not. Some people blame it on lack of staff, I can see that is a problem but I also have experienced serious attitude problems from staff, who appear to resent any demands on their attention (other than dishing out tablets and faffing about with bits of paper or converging in the office, rarely to step foot outside).

One could blame lack of staff morale but working in MH services should be a vocation...for those who want to make positive differences to the lives of those they provide care to. More and more it is seeming as a cop out for those who aree happy to be compliant in a service that is serving senior management and 'yes' people but nobody else very well.

I think the NHS Service is being stripped away, particularly the MH services. In fact, I can see that they will be modernised to oblivion and by modernisation I mean there will be no real service for people to access..more a recovery model where everyone is empowered by being 'discharged' without any say in the matter.

I think it is easier to get rid of MH services than other parts of the NHS (on the grounds that nobody is that bothered about people with mental illness..unless they are running at them with a pick axe). However, the thin edge of the wedge is still part of the wedge and 'streamlining' will go on across the board and the rare outcry by the general public will decide which bits the government will decide to focus on.

Until such time as private care is seen as a viable option to the public because there isn't anything else on offer.

The future is not orange....that is unless phone companies decide to offer care services.

Why Lake Cocytus?

Dante's "Inferno" takes us on a journey through to the deepest layer of Hell, passing down through layers of fire. Within this Ninth Layer there is no flame, there is a lake of ice. Imprisoned within this are the those of greatest evil, those of greatest betrayal. Rather a puzzle to me, this one. Is it a terrible place, manifesting evil incarnate? Or is Lake Cocytus a good thing, containing the world's greatest evils?

Good or evil this place, this Lake Cocytus, is my space to entomb the thoughts and musings best interred in ice.

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